What Executive Leaders can do to Retain the "Missing Middle"

Executives often ask about budget, patient flow, or staffing numbers, but when was the last time you asked a senior nurse: 'What is the pebble in your shoe this week?'

In this episode of Better Every Shift, Naomi and Tubi tackle the crisis of the missing middle—those quietly reliable senior nurses who do the heavy lifting but are now leaving the profession in droves. We move past the standard focus on "vacancies" to discuss capability risk: the invaluable organizational memory and clinical expertise that walk out the door when a mid-career professional resigns.

We explore why it’s rarely a massive systemic issue that drives these professionals away, but rather the "tiny, annoying things"—like a device that never works or a frustrating system—that finally push them over the edge. Stick around to learn the four essential retention conversations every executive should be having and how a coach-like approach to executive rounding can stop the "quiet cracking" of your most valuable staff.

Key Discussion Points

The Missing Middle: Why our most reliable nurses are leaving for other work—not just retiring—and the $100,000+ cost of losing that expertise.

Vacancies vs. Capability Risk: Shifting the executive focus from "bums on seats" to the clinical relationships and safety culture lost during mid-career exits.

The "Pebble in the Shoe": How identifying and fixing the "little things" (like broken equipment or annoying tech) can have a larger impact than big-level data fixes.

Quiet Cracking: Identifying the subtle signs of disengagement—skipping lunch, hiding in offices, or a drop in "generosity of spirit"—before a resignation letter arrives.

Four Retention Conversations: A simple framework for executives to ask: What do you enjoy? What’s frustrating? What’s your next move? What would make you leave?

Transferable Skills and Streams: Why the nursing profession struggles to support mid-career moves between education, management, and clinical roles.

Authority vs. Responsibility: Supporting leaders who have the reporting burden but lack the authority to fix the systems they manage.

Timestamps

[00:00:00] Intro: The "Pebble in the Shoe" Hook and the Missing Middle.

[00:02:00] The Heavy Lifters: Why "quietly reliable" nurses feel inequity.

[00:05:00] Capability Risk: Why senior resignations cost more than $100,000.

[00:11:00] Life Stressors: Supporting the "sandwich generation" with flexible care options.

[00:13:00] Executive Rounding: Moving from budget questions to "What’s the pebble?".

[00:15:00] The Coach-Like Approach: Using curiosity to restore autonomy and belonging.

[00:18:00] The Retention Framework: Four questions to ask your team today.

[00:23:00] Quiet Cracking: Spotting the nuance of disengagement before it’s too late.

[00:27:00] Call to Action: Pick one experienced nurse and ask the question.

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Transcript

SPEAKER_01 0:09

Executives often ask about budget, patient flow, or staffing numbers. But when was the last time you asked a senior nurse what is the pebble in your shoe this week? It's really the big systemic issues that drive our most reliable people away. It's the tiny, annoying things, the device that won't work, or the system that's constantly frustrating, that finally make a mid-year, mid-career professional decide they've had enough. Welcome to Better Every Shift, the show for brilliant healthcare professionals with great ideas who are ready to make real impact. I'm Naomi, and together with Tubi, we draw on our lived experience and our curiosity to help you bridge the gap between clinical stress and professional efficacy. Today we're exploring the missing middle. Those quietly reliable nurses who do the heavy lifting but are now leaving the profession in droves. When these senior nurses leave, they take invaluable organisational memory and clinical expertise with them. Stick around to learn why your executive rounding needs to move away from big data and toward the little things that actually determine if your best people stay or go.

SPEAKER_00 1:41

That's our our biggest area of loss in the nursing profession currently is people at this senior level who are leaving for other work. Yeah.

SPEAKER_03 1:52

Yeah.

SPEAKER_01 1:52

So not necessarily retiring. No. They're leaving to do other things. Some are retiring early and very different to what they had planned. But they've decided that actually retiring is a better option than staying where they are. What things do you hear from nurses that are in that space, or what do you see that's not being discussed in the right forums?

SPEAKER_00 2:20

There's a couple of things. One is these are the quietly reliable nurses often. They always show up, they do their work, they carry a big load in terms of their clinical competency, they're teaching others, they're doing a huge amount of the heavy lifting in the work area. There's a sense of inequity. The more they do, the more they get given to do.

SPEAKER_03 2:47

Yes.

SPEAKER_00 2:48

This connects back into succession planning. When there's not a good succession plan, the default is to go to this group of nurses and just continue to heat more on them. Something else I hear a lot about is they don't get any feedback unless they do something wrong. So there's no acknowledgement or recognition of that heavy lifting that they are doing. There is a shifting expectation now around being promoted. I think we've discussed this before when I was nursing. There's tons of senior level ones, very few level twos. But now there's a lot more level twos, and it is a it's a very well-defined career pathway, but not everybody gets there, and not everybody gets it. And people get disenchanted and perhaps aren't well led into how to prepare themselves for that. It's not often not clear what do I need to do to formally progress. What's required at each particular level? What are the gaps in my current knowledge, expertise, experience, capability that I need to fill, and how will I do that? So I think there's a growth and development lack of clarity.

SPEAKER_01 4:12

Yeah. What's coming up for you? Following on from that, there's there's a lack of clarity, but their opportunity narrows. So, as you said, there's only so many high-level positions, and as you go up, that field narrows. We've improved now with nurse practitioners being a role and increased scope positions being a role so people can stay clinical and still progress up the career pathway. But those positions are limited. If you're wanting to go up the manager pathway, there's only so many of those roles. As individuals, we haven't thought very well about what are all of my options here. What could I do that's a little bit different that maybe doesn't follow that pathway but gets me to what I want in a slightly different way? And as services, we certainly don't do it well, and we're not looking at the nuanced data. We look at the very specific metrics of who's leaving and when. We're not looking at what gaps are those people leaving when they go broader than just the a bum on a seat. We focus on vacancies. We don't focus on capability risk. When a senior nurse leaves, what expertise, relationships, and organizational memory left with them?

SPEAKER_00 5:37

There's a huge personal element here to why people leave at that at this particular time, age, and stage of their lives and their careers. But it seems to me that cross-organization collaboration, particularly around that workforce planning component, could be really useful. What came to mind for me as you were talking was career counselling. Is there opportunities at certain stages of people's careers where actually counselling would be a useful way to motivate and inspire people about the future of their career?

SPEAKER_01 6:23

Absolutely. I think that's a really useful way of doing it. We actually did it a few years ago, which was super fun. We invited all of our services to be part of an expo. So we had a nursing expo internal. We did have students there, so any students that were on site were invited. It only went for a couple of hours, but all the teams came and had something related to their service. The Scrub Scouts and anesthetic team. They came and did very hands-on. The Scrub Scouts had all the different instruments and got people to name them and explain what each of them were, and there's hundreds of them. And then anaesthetics talked about the drugs that they used in anaesthetics. ICU had gizmos and gadgets and pumps and all sorts of crazy things and had a little scenario going. The graduate team set up a fortune teller stand to help coach some questions with new graduates around what maybe they should consider. And it was a really fun little game, but it answered some really useful questions. And we also had a job interview coach. So we had somebody who would run this mock interview, and it might be a mock interview with five people, and would coach them about their responses that they gave, which was super fun. Our renal nurses that had peritoneal dialysis setups on themselves for people to connect and disconnect. Palliative care was there and all sorts of fun things. But there were some really useful conversations about what do we do next.

SPEAKER_00 8:01

It's brought to mind for me. We talked about streaming in nursing. So if I'm at a level two in Periop, for example, can I move as a level two into a surgical or a medical ward or ED? And what are the skills that are required at a level two? Like I need to be a clinical expert. And what else? If I want to change streams, am I going to have to drop down?

SPEAKER_03 8:30

Yeah.

SPEAKER_00 8:31

And if I drop down, then that brings in the personal for me because actually I've created a lifestyle around the salary I collect now.

SPEAKER_01 8:41

Yeah. Moving around is something we generally don't support very well in nursing, and we don't set up a pathway. And it's very black and white, which makes it transparent, which is good, but it detracts from the skills that people do have.

SPEAKER_00 9:00

I would agree, and that comes back to what do we view are transferable skills and why do we think they're transferable? And I think at the moment that's a there's a very fixed mindset on that. There's a lot more flexibility than than we would first allow. It's important because when a qualified nurse leaves an organization, it's so much money. The cost to the organization in terms of quality and safety of care, roles in the in their work area, their capacity to provide resilience and expertise across the whole work area, that's worth much more than $100,000.

SPEAKER_01 9:38

Yeah, it's invaluable. And there are things we can measure which we don't measure very well. You know, we've got the financial elements, but the number of people that now are having to pick up a level of work that they're not quite ready for without that support is very challenging. The little projects that they were doing, just being able to get that piece of work done and work with that crazy system that's really frustrating. Being able to navigate it, whereas somebody else now is going to take a long time to work out how to do it. There is that succession planning initiative that we need to do, but we there's a limit to where that can fit in. If people are struggling to do their general work, adding more things on them is not helpful.

SPEAKER_00 10:22

Oh, absolutely. Thinking about my own career, and I guess I could be classified as a mid-career leader because I had been working more than 10 years when I left. When I look back on that experience, while my last job I was working often solo in the semi-rural emergency department, I didn't value my own expertise and my capacity to do that and what I actually brought. So that was one part of it. But there was another part where I was done with the years of missing out on birthdays, weddings, funerals, holidays, uh sleep, the little things, the rotate the rotating shifts, school, missing out on school events. When we're talking about mid-career nurses, they're often got young or moving into teenage kids, their parents might be a bit older. What else do you think outside of work are stressors on this group?

SPEAKER_01 11:31

You've probably captured most of them, and none of those should be underestimated. To support most people with those things is not hugely difficult. It does take some really clear conversations about what is it that's needed, how long is this needed for? A debate that I've seen here for a long time is the potential to have childcare on site. But it doesn't solve the whole problem of childcare. As a parent, I may not want my children to be in childcare at eight o'clock at night while I'm working a late shift. That I may not feel very comfortable with that as an ongoing thing, and it may not provide good routine and space for my children. So while that may be part of it, some of these conversations need to be what can we do that is helpful and how do we set this up that it it can be workable for both. In most circumstances, if you can support those things, and it might be that somebody needs to go and care for a parent for a few weeks or a month, it's frustrating for managers because they have to backfill. So there's some extra work around it, but then you will have somebody who feels supported by their organisation who stays and contributes for much longer. Gone are the days that people feel that they owe the service anything, people don't feel loyalty and that they need to maintain that loyalty for forever, but they will feel value in the workplace and will be more inclined to stay if they've been supported through the things that they needed. Whereas they will be very quick to leave if other opportunities come up, if they haven't been supported.

SPEAKER_00 13:23

One of the the challenges is that they don't really know what they're dealing with because they're too worried about asking the question, what do you want? Although it's not explicit, the thinking goes, if I ask what do you want, I have to be prepared to give it. I don't agree with that. You can ask what they want and not it not be implicit that you're going to provide that. No, completely.

SPEAKER_01 13:50

It's about asking the question. The most useful thing that executive teams can do is to a lot of them will do executive rounding. They might have conversations with managers about what's happening in your budget, what's your staffing like today, even, what's your patient flow like today is probably the most common question. A more useful question for executive to go and ask is, hey, how you going? What is the pebble in your shoe this week? The little thing, the little thing that's just really annoying, it's stuck in your shoe, and what can I help do to remove it? You may not be able to do anything. Sometimes just articulating it is enough. Just asking what that little thing is, because it is often the really little things that are the most tiring. The big thing the knowing that it's really busy, that just is the thing. But the do you know what I've called IT four times this week and I can't get this device working. It is super annoying, and executive are often unaware of the impact that those little things are having, and that actually it's an issue for ten places, and a really simple fix at that executive level makes a world of difference to the managers or the clinicians on the floor. That's probably the most useful fix that executive can step into is moving away from that big level data down to the little things and being really intentional and specific with people.

SPEAKER_00 15:32

I might be a little biased, but I think executives coming with a coach-like approach to those conversations and a level of curiosity first. What's on your mind? What's the real challenge here for you? What do you want? What can I help with? Are such simple questions to ask. None of them are saying, I'll fix it for you. No. That can be one of the things that needs to happen. But just having that conversation with a manager is so powerful for them to feel heard. Yes. To hold that space enough for maybe them to figure it out. They just haven't had anyone actually provide that for them yet.

SPEAKER_01 16:18

One of the other challenges we see as leaders move up, particularly into the management space and even into executive roles, is their level of responsibility grows really significantly. And their workload grows significantly with that responsibility. But they actually don't gain any authority or any ability to control the things that would make a big difference in their workplace. But actually they can't control it. They've got a whole level of responsibility, a whole level of reporting that they have to do, they've got a lot of answers that they need to make, they've got lots of tasks that need to get done, but they actually have no authority about getting the fix on it, which is really frustrating for managers and leaders as they go up. And we need to do better at acknowledging that and supporting people through that, uh, because it's super frustrating and where a lot of people get really stuck. Thought once I was there, I could just do it.

SPEAKER_00 17:23

Yeah. I could make it the way I thought it needed to be. We've talked about this question a lot, but what's in your control? Yeah. And often it's not much. There are three core human needs autonomy, belonging, and competence. I don't think we talk about or understand that, but even just being asked, what would you like to have autonomy over that you don't currently have it over? Yeah. Ask the question: what's the challenge or the worry or the problem that's needling away at you? Like you said, what's the pebble in your shoe? Let's first identify and clarify what it actually is. Is it something within your control? If it is within your control, what what autonomy have you got to actually make changes to this? And if you don't have time to do it, who in your team could do it?

SPEAKER_03 18:12

Yeah.

SPEAKER_00 18:12

These are all coaching questions that a leader could ask a manager.

unknown 18:17

Yeah.

SPEAKER_00 18:17

Help them sort through what they're experiencing.

SPEAKER_01 18:21

Four attention conversations that executives should be having with their teens. What are you enjoying most right now? What's frustrating you? What do you want in your next career move? What would make you leave?

SPEAKER_00 18:39

I think you touched on one of these things as well. People are often promoted, and I'm seeing it more and more and more, which is heartbreaking. They're promoted beyond their competence because they're the most competent. Or the loudest. Or the loudest, or the most pliable, or the least likely to rock the boat, or the most pleasant to work with. And so they get promoted beyond their competence, and then they're not well supported. And they don't have those skills, and then it just undermines their confidence and competence ultimately. And then they leave.

SPEAKER_01 19:30

And peers often notice first that a manager or leader is struggling and that things are not quite right. What few tips would you give a peer to support their colleague that they see that is starting to withdraw, not attend meetings, have something surly to say in meetings?

SPEAKER_00 19:52

So at level with us, I would say, I've noticed this. What's on your mind? What's happening for you? And just open up a broadly curious coaching conversation and just understand, let them talk. I think we assume what people are struggling with or challenged by. So that's where I would start. I noticed, and then the question. So it might be what's on your mind or what's what's happening for you right now. How would you support a peer?

SPEAKER_01 20:33

I would physically drop in on them. Not that physically. I would call in and invite them for coffee, or bring coffee and sit down with them and go, hey, I missed you at that meeting yesterday. We talked about this, this, and this. Is that a problem for you? Or how are you going with that? Or I know this happened. How how's that going? Tell me where you're stuck at the minute. And probably one of the most common things I do is reorientate people as to the things that they can't control. And just notice it isn't in your control. I understand that you're worrying about it, but it's not the thing. This is your This is the thing that you can impact over here and reminding them of where they do have really big impact and holding them to that.

SPEAKER_00 21:27

What I see is people working very isolated from other executives. So if you're an executive peer, how often would you see perhaps someone's absence or struggle?

SPEAKER_01 21:46

It depends on the individuals, but if there's an absence you'll see it within a few days. You know, that you'll see they're not at that meeting. They go to another meeting, but I've noticed this is the second time they've not come to this meeting. This is kind of a key meeting that they should come to. There's a whole bunch of meetings none of us should go to. Yeah, that's a whole nother podcast. Whether they think that they need to solve something else, that there's a reason that they're getting caught up, then we should touch in on people and check what we need to do to support them. Um maybe doing something else that's far more useful and much better than the meeting. Great. Then we should all stop going to the meeting and go do whatever they're doing. Very often that's not the case, though, so you need to ask.

SPEAKER_03 22:45

Yeah.

SPEAKER_01 22:46

Without the judgment about they should be attending the meeting, but uh concern what's got you caught up because I would think that this is a useful thing for you.

SPEAKER_00 22:56

I have seen something recently called quiet cracking, where people are still getting the work done, but there's that social aspect is dropping off. Or it might be quieter than usual, they're not going to lunches, they're not taking lunch with everybody else, they're hiding, um, they're less patient or tolerant than they would normally be. We've talked about people not coming to meetings or people not um showing up, but what are the more subtle nuanced signs that you think you've seen or people may have seen that relate to before someone starts taking lots of personal leave or those bigger, more obvious things?

SPEAKER_01 23:42

People working to rule. We should all probably work more to rule, but when people become very no, I'm just doing what you asked, it's probably a sign. And I think as you mentioned, the lunch breaks is something that generally is a problem in many, many healthcare services. And it continues to be important as you move up the ranks, and it is worn as a badge of honour. Well, I don't get lunch, that's not okay. It is even less okay when people are then not eating altogether or not taking a few minutes to prep themselves between meetings and don't feel that they've got capacity to do that. Don't think they're a problem. And if they're not engaging with other people in a way that they have previously, that's they're probably the big ones. The other is the tone in emails. It's often early, but repeated level in emails is probably the other one. I'm not expecting that people work outside of rule or work longer or work harder, but there is a generosity of spirit that and I think that that's an important cue to something we need to look at this.

SPEAKER_00 25:08

And it's hard to measure that generosity of spirit as well. You know it when you see it, you know it when it's not there, but it's really hard to articulate and measure. Drawing on what Renee Thompson said about pointing out a behaviour. If you saw someone working to rule and it was a change for them, what would you do?

SPEAKER_01 25:29

I usually call it out, and it would depend a little bit on my relationship with the person, but I would articulate this is what I'm seeing. I'm this is out of character for you. Is there something going on? Very often when I've seen it, we've already had conversations about what's going on, and so I can then my conversation is what do you need to be able to step back in? Do you just need a bit of time? Do we come back and talk about this next week? And sometimes that's is all it is. Often it's not a sudden thing, it is part of that whole conversation about what's going on. What did you get stuck with? I noticed your eye roll in that meeting. Tell me about that. Yeah, what else was going on?

SPEAKER_00 26:16

Or I noticed you're ticking the box, which is not like you.

SPEAKER_01 26:20

Yeah. What other supports have you got? Do we need to re-look at what your workload is? Asking those very specific questions and looking for the less obvious markers. You know, we're good at looking at that really high-level data and going, oh whoops, our turnover's gone really high when it's too late. Whereas there's lots of things that we can look at earlier, but they are less tangible. And so just being aware of you can't do everything, but maybe it is that the two of you can catch up and talk about one thing each and just acknowledge which bits are hard.

SPEAKER_00 26:55

For me, also it's that paying attention.

SPEAKER_01 26:58

Yeah.

SPEAKER_00 26:59

There are some senior roles that are empty right now.

unknown 27:02

Yeah.

SPEAKER_00 27:04

Having that conversation. What do I need to do to support you? Because I recognise your workload hasn't diminished. You're missing some senior people here.

SPEAKER_02 27:13

Yeah.

SPEAKER_00 27:13

Let's have a conversation about priorities, energy, and escalation pathway that we both agree to.

SPEAKER_01 27:21

And which work do we not have capacity to do right now? I don't think we're very good at doing it. We're kind of, well, we're a hospital, we have to yeah, we do, but there are things that we can not do. And that may need to be for a really short period of time, but have those conversations. Yeah.

SPEAKER_00 27:42

We're back to uh communication again. Yeah. Who does that?

SPEAKER_01 27:47

Who would have do it? The nurses we're talking about aren't usually the loudest. They're often the reliable ones, the ones carrying expertise, relationships, and culture. If we wait until they resign to pay attention, we've waited too long. This week, pick one experienced nurse, ask, What's the pebble in your shoe right now? Thank you so much.

SPEAKER_00 28:14

Thank you.